Pre-hospital care is defined as care and treatment provided at the scene of an accident or acute and sudden illness in an ambulance, emergency vehicle or helicopter (Advanced Life Support Group 2011a, Ahl & Nystrom 2012). Historically, nurses have played an important role in the shaping of pre-hospital emergency care in the UK. The contribution of the hospital flying squad and the cardiac ambulance and the nurses working on them should not be underestimated. Not only did these teams provide a service that filled a therapeutic vacuum in patient care, but they were also instrumental in the development and evolution of these services. The work of both the flying squad and the cardiac ambulance significantly influenced the development of ambulance service and ultimately the birth of the paramedic.

The demise of the hospital flying squad has resulted from a reduced need, partly because of the increasing sophistication of ambulance service provision, enabling ambulance staff to manage increasingly complex clinical situations, complemented by the role played by immediate care doctors responding to incidents in partnership with the ambulance service. Perhaps more influential in the demise of the mobile hospital team has been the increasing workloads of Emergency Departments (ED) and their limited resources to release staff to attend incident scenes on a regular basis.

The role for nurses in responding to the scene of emergency incidents has substantially contracted; however, the potential for nursing input at the scene of a major incident remains a possibility. There are developing areas of pre-hospital practice in which the role of nurses remains, firstly the role in inter-hospital transfer of the critically ill and injured, and secondly working as Emergency Care Practitioners (ECPs).

Whatever role nurses play in their contribution to pre-hospital emergency care, they must be able to do so safely and competently. The professional requirements, set down by the Nursing and Midwifery Council (2008), to provide high standards of practice at all times, to use the best available evidence, to keep skills and knowledge up to date and to recognize and work within the limits of personal competence remain valid when working in the pre-hospital environment just as they do in the ED.

Major incidents

It is neither essential nor desirable for all acute hospitals to be able to provide a mobile team in the event of a major incident. The responsibilities for ensuring mobile teams are available rests with the relevant regional or national health commissioning body. They may nominate those hospitals who will be responsible for deploying a Medical Emergency Response Incident Team (MERIT) to the scene of the incident, if requested to do so (DoH Emergency Preparedness Division 2005). In areas where active immediate care or British Association for Immediate Care (BASICS) schemes are operating, the relevant health board may nominate them to provide the on scene response rather than the acute hospitals. It is, however, essential that the emergency department staff are familiar with the local arrangements in their area.

Those hospitals that are identified as being able to provide a MERIT must ensure staff identified to deploy, the staff must understand the role they are to fulfil in the event of an incident, have the necessary competencies to fulfil that role and have received training to fulfil those competencies (DoH Emergency Preparedness Division 2005, 2007, Bland 2011).

However, there are circumstances, although infrequent, when an ED may be requested to provide medical and nursing support at the scene of a major incident to support their ambulance service colleagues. Given that such incidents are likely to be complex and high profile there is a risk that staff agree to respond without carefully considering if they and their fellow healthcare providers can bring additional expertise that will be of clear benefit to patient care and, in addition, to those services already provided.

Use and function of mobile teams

It is essential that guidelines for the call-out of the team and its intended role are clearly defined in the major incident procedures of all interested parties, predominantly, but not exclusively, the acute hospital, the ambulance trust, and the health authority. There is, unfortunately, a long history of hospital teams being called to the scene of an incident where their role has not been clearly defined beforehand, resulting in the team, at best, contributing little to patient outcome and, at worst, putting themselves and others at risk.

In addition to the clarity of purpose, any proposed team activity must be supported with education, training, rehearsal and operational experience. Failure to do so will result in an ill-equipped, poorly trained, undisciplined team working in an environment in which there is no place for them. The need for regular update training and rehearsal is evermore important because requests for assistance are relatively rare, team members are unlikely to have much experience in this aspect of practice.

Unfortunately there is little guidance available to help organizations identify the best use of the mobile team, the criteria for deployment, the equipment the team should have access to and the training team members require. Although arguing for a medical specialty of pre-hospital and retrieval medicine, the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh, give an insight into what competencies may be required of team members in executing their role (Faculty Pre-hospital Care, Royal College of Surgeons of Edinburgh, 2008). They suggest that the specialist role include:

• supporting complex decision making – balancing the risks and benefits associated with at-scene clinical interventions

• supporting complex transport decisions – balancing the risks and benefits associated with pre-hospital triage, mode of transport and level of clinical escort

• provision of alternative forms of analgesic drugs and techniques

• provision of pre-hospital procedural sedation

• provision of pre-hospital emergency anaesthesia

• provision of organ support

• supporting the clinical use of critical care drugs and infusions, such as anaesthesia, vasoactive drugs and blood products

• use of complex monitoring and near patient investigation techniques, such as invasive haemodynamic monitoring and ultrasound.

In addition to the clinical skills required to provide added value to patient care, it is essential that team members have the skills that allow them to operate safely in the pre-hospital environment. They must be both safe and competent to work in environments that are inherently dangerous and where clinical conditions are suboptimal, such as poor lighting, confined spaces, and inclement weather. Additional specialist skills may also be necessary when working at incidents that involve potential hazardous materials.

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